HGSIL of the Cervix on Pap Smear: What it Means

Frederick R. Jelovsek MD, MS

"I have had my first abnormal pap smear. It showed "high grade epithelial lesions". The ob/gyn said that the LEEP is the next step, after my colposcopy results are revealed. Does this mean that I have just cervical dysplasia, or is it really cervical cancer. I am scared, although I have a family background of various types of cancers on both sides of my family. " Carol

The Pap smear is a screening tool and its classifications indicate to the doctor whether there is a risk of having cervical cancer. The classification system your doctor's Pap laboratory is using is called the Bethesda System. In this classification HGSIL, which stands for high grade squamous intraepithelial lesion, indicates changes in the cells of the cervix which may represent a moderate or severe dysplasia of the cervix.

The next step is to have a colposcopically directed biopsy of the cervix to see whether the changes on the cervix are the same as the Pap, worse than the Pap indicates (carcinoma in situ, or invasive cancer) or less severe (mild dysplasia, inflammation) than the Pap indicated. The biopsy result is the "gold standard", not the Pap result. Your further treatment and follow-up depend upon what the biopsy shows.

Does high grade epithelial lesion (HGSIL) on Pap smear mean I may have cancer?

A high grade squamous intraepithelial lesion on Pap smear does not indicate cancer. It usually indicates what is called moderate or severe dysplasia. However, since the Pap smear is a screening test, the actual changes on the cervix can be worse and actually be an invasive cervical cancer. This would be very uncommon and the chance of a Pap smear showing HGSIL and of there being an invasive cancer of the cervix already present would be less than 1%. In fact only about 1.5% of women with a HGSIL Pap smear will progress to having invasive cancer of the cervix within the next 24 months (1).

Since cervical dysplasia can progress to an invasive cervical cancer over time, it is very important to have it treated if your biopsy shows dysplasia is present. Treatment will remove or destroy the affected cells on the cervix and the hope is that when the body heals over that tissue, the new cells will not be affected by dysplasia. Destruction of those cells can be performed by loop electrical excision (LEEP, LLETZ). cryotherapy, cautery or laser excision or ablation. In general, any destructive procedure of dysplastic cervical cells is about 85% curative over the long run.

What is the treatment for HGSIL or moderate or severe dysplasia?

It is important to treat the tissue biopsy results and not the Pap smear. Assuming the biopsy shows moderate or severe dysplasia, the most frequently used treatment right now is the loop electrical excision procedure (LEEP). In this procedure, the cells that are abnormal and usually located at the transformation zone of the cervix are excised.

What is involved in having a LEEP or LLETZ procedure done to the cervix?

The LEEP procedure first starts with a colposcopy. You lie on an exam table with your feet in stirrups like a regular pelvic exam. A special non-conducting vaginal speculum is place in the vagina. The cervix is swabbed or sprayed with acetic acid about the strength of a bottled white vinegar. A colposcope, which is a low power microscope, is used to look at the areas on the cervix that are affected. Following identification of the area to be excised, a xylocaine filled syringe is used to inject local anesthetic at several different points around the cervix. The xylocaine may have a small amount of epinephrine to lessen the amount of bleeding from the denuded cervix. Sometimes this epinephrine will cause your heart to beat very fast. Let the doctor know about that.

When the cervix is numb, an electrical wire loop is used to scoop a shallow bowl shaped piece of cervical tissue containing the areas that stain abnormally with the acetic acid. During this excision, some smoke is released from the cervix and a vacuum exhaust is used close to the end of the speculum to clear the smoke so the doctor can see well enough to complete the procedure. The vacuum tends to make a loud noise. Following this, the doctor may want to look again at the cervix with the colposcope to make sure all of the abnormal tissue was removed.

At this point there is still a small amount of bleeding from the excised surface of the cervix. The doctor may cauterize the bleeding areas or swab on an astringent solution to stop the bleeding. Sometimes this astringent solution causes a grayish discharge for a day or two later.

What are complications of the LEEP procedure?

Bleeding is the main complication of a LEEP procedure. It happens about 4% of the time (2) but serious bleeding requiring prolonged observation, stitches or even blood transfusion are in the range of 1.5% (3). Infection can occur following LEEP but it seems to occur less than 5% of the time and even less if prophylactic antibiotics are given.

The squamocolumnar junction of the skin of the cervix is the area where dysplasia is most likely to recur. Its position is often changed to where it cannot be visualized with colposcopy when any type of conization procedure is done. With LEEP this may be as high as 20% of the time (4). It does not usually affect subsequent Pap smears but it can make a next colposcopy difficult.

What kind of follow-up will I have after a LEEP procedure?

Immediate Pap smears have a moderate amount of artifact so they are not usually performed (5). The first Pap smear is performed at about 3-4 months after the LEEP procedure. The procedure itself is over 95% effective at removing all the abnormal tissue but the success rate of a LEEP at totally eradicating an abnormal Pap smear is estimated to be about 75-85% especially in the face of moderate or severe dysplasia. This discrepancy is because most dysplasia is felt to be due to the human papilloma virus (HPV) and the virus is still present in cells around the area that was removed with the LEEP. HPV may reinfect the new cells and the dysplasia recurs with return of an abnormal Pap.

Pap smears are repeated until they return to normal and there are 3 consecutive negative smears. Then you just go back to having Pap smears on a routine yearly basis. In the alternative, if the Pap reverts to a high grade lesion (HGSIL), then another colposcopy and biopsy is performed and the process starts over again.

If you have ever had a Pap smear classified as HGSIL or had a biopsy of the cervix with moderate or severe dysplasia, or carcinoma insitu, then you should continue to have an annual Pap smear even if you end up having a hysterectomy later.